1. 5 th Annual Forum Wednesday 28 th April 2010 Royal Hospital Kilmainham ‘Promoting Positive Mental Health and Reducing Stigma’

2. World Health Organisation Collaborating Centre for Health Promotion Research National University of Ireland, Galway Ollscoil na hÉireann, Gaillimh Stigma Reduction and Mental Health Promotion What Works? Professor Margaret Barry

3. Barry NOSP April 2010 Overview Concepts of mental health and wellbeing Adopting a mental health promotion approach –why stigma is important for mental health promotion Challenging stigma and its effects –the effectiveness of anti-stigma interventions –interventions in schools and workplaces

4. Barry NOSP April 2010 Concepts of mental health Concepts of mental health vary as a function of time, place, culture and context –changing and competing perspectives concerning the nature of mental health and ill-health Mental health has been conceived as a medical, psychological and sociological phenomenon - disease entity approach - normality and abnormality; ‘ideal self’ - social construct - ‘deviance’ and social causation - impact of poverty, social position, poor housing, unemployment, social stressors The merging of perspectives - biopsychosocial model

5. Barry NOSP April 2010 Concepts of mental health Relationship between mental health and mental disorder continuum or separate entities? Population approach - continuous distribution of mental health and mental disorder across the population Mental health is fundamental to good health and quality of life ‘complete physical, mental and social well-being’ ‘a resource for everyday life which enables us to manage our lives successfully’ Mental health as an integral part of health and wellbeing (Lancet series on Global Mental Health 2007) –there is no health without mental health

6. Barry NOSP April 2010 Concepts of positive mental health Conceptualisations of positive mental health (Keyes, 2002; Huppert, 2005; Ryff et al., 2006) –hedonic - subjective well-being and life satisfaction –eudaimonic - positive functioning, engagement, fulfilment and social well-being Keyes’ concept of optimal mental health or ‘flourishing’ –more than the absence of mental illness Measures of positive mental health at population level

7. Barry NOSP April 2010 Mental health and wellbeing Mental Health Action Plan for Europe (WHO, 2005) – ‘mental health is an essential component of social cohesion, productivity and peace and stability in the living environment, contributing to social capital and economic development in societies” UK Foresight Project on Mental Capital and Wellbeing (2008) “ A key message is that if we are to prosper and thrive in our changing society and in an increasingly connected and competitive world, both our mental and material resources will be vital. Encouraging and enabling everyone to realise their potential throughout their lives will be crucial for our future prosperity and wellbeing” (www.foresight.gov.uk) Barry and Friedli (2008) determinants of positive mental health State-of-Science Review: SR-B3

8. Barry NOSP April 2010 A policy focus on wellbeing Richard Layard (2005) ‘Happiness: Lessons from a New Science?’ – the economics of wellbeing New Economics Foundation - A Well-being Manifesto for a Flourishing Society “What would politics look like if promoting people’s well- being was one of the government’s main aims?” –integration of social, economic and ecological policies Wellbeing Indicators at country level –National Accounts of Well-being (New Economics Foundation, 2008) –Canadian Index of Wellbeing (2009)

9. Barry NOSP April 2010 Adopting a mental health promotion approach Focus on promoting population mental health -enhancing the strengths and competencies of individuals, communities and society -addressing the broader determinants of positive mental health Multidisciplinary - theories and methods Builds on the basic concepts and principles of health promotion Where is mental health created? - contexts and settings where we live our lives

10. Barry NOSP April 2010 Health Promotion action areas Build healthy public policy Create supportive environments Reorient health services Strengthen community action Develop personal skill combined into Health Promotion strategies Systems Policies environment organisation community person Systems scale Health Promotion Principles (participation, empowerment, equity) Health Promotion Model (WHO Ottawa Charter) The process of enabling people to increase control over their health and the determinants of health micro - macro Assessment Planning Implementation Evaluation Barry NOSP April 201010

11. Barry NOSP April 201011 Universal Selective Indicated Case identification Standard treatment for known disorders Compliance with long-term treatment After-care (including rehabilitation) Empowerment Competence Supportive Environments Strategies for promoting well-being & quality of life Resilience Barry, M.M. (2001) International Journal of Mental Health Promotion, 3(1) 25-34.

12. Barry NOSP April 2010 Determinants of mental health Healthy structures - economic, political, social and cultural framework for developing and maintaining positive mental health Citizenship - social support, sense of social integration and inclusion Emotional resilience - self-esteem, coping, life skills, sense of control

13. Barry NOSP April 2010 Adopting a mental health promotion approach Growing international evidence base on the effectiveness of mental health promotion practice (Hosman & Jané-Llopis, 1999; WHO, 2004; Jané-Llopis et al., 2005; Herrman et al., 2005; Keleher & Armstrong, 2005; Barry & Jenkins, 2007) Evidence sources Health Evidence Canada Cochrane database of systematic reviews US Mental Health and Substance Abuse (SAMSHA) UK NICE - evidence briefings There is sufficient knowledge to move evidence into practice (Jané-Llopis, Barry, Hosman and Patel (IUHPE Special Issue, 2005)

14. Barry NOSP April 2010 Adopting a mental health promotion approach Feasibility of implementing effective mental health promotion programmes across a range of diverse population groups and settings (Barry & Jenkins, 2007) Generate multiple positive outcomes across social and personal health domains (Herrman et al., 2005) Strong economic case for investment – interventions that can be sustained at a reasonable cost (Friedli & Parsonage, 2007; Knapp et al., 2008) International policy and practice developments - dissemination and adoption of evidence-based practice

15. Barry NOSP April 2010 Findings from SLÁN 2007 study (Barry et al., 2009) Mental health and social wellbeing of 10,364 Irish adults Positive and negative mental heath as part of the national health survey Lower levels of loneliness and higher levels of social support are associated with positive mental health Gender and social and economic factors Markers of social advantage - higher income, employed, higher education - associated with better mental health

16. Barry NOSP April 2010 Positive Mental Health Barry NOSP April 201016

17. Barry NOSP April 2010 Psychological Distress and Energy and Vitality by Income Barry NOSP April 201017

18. Barry NOSP April 2010 Psychological Distress and Energy and Vitality by Social Support Barry NOSP April 201018

19. Barry NOSP April 2010 Flourishing by Health Behaviour Barry NOSP April 201019

20. Barry NOSP April 2010 Determinants of mental health and wellbeing Eurobarometer study (Lehtinen et al., 2005) – 2002 survey of positive mental health across 11 European countries Dolan et al., 2006 - review of causative factors associated with subjective wellbeing (analysis of British Household Panel Survey) Both studies identified relationships and social support, income, health, and employment as being positively associated with mental health and well- being

21. Barry NOSP April 2010 Adopting a mental health promotion approach Individual level – identity, self-esteem, efficacy and life skills Social networks - social relationships, support, exchange, sense of social belonging and inclusion Community level – community involvement, civic engagement, leisure, membership of clubs etc., volunteering Societal level – cultural, economic and social policies -role in wider society, work, citizenship, democratic participation, environment Access to resources and opportunities »supportive relationships, education, employment, opportunities for social inclusion Stigma and discrimination denies access to life opportunities and resources

22. Barry NOSP April 2010 Stigma “the situation of the individual who is disqualified from full acceptance”; “an attribute that is deeply discrediting and reduces the bearer from a whole and usual person to a tainted, discounted one” (Goffman, 1963) ‘a combination of stereotyped beliefs, prejudiced attitudes and discriminatory behaviours toward outgroups… resulting in reduced life opportunities for those who are devalued’ (Hinshaw and Stier, 2008) Mental disorders are one of the most stigmatised conditions

23. Barry NOSP April 2010 Impact of Stigma People with mental health problems consistently identify stigma, discrimination and social exclusion as major barriers to their health, well-being and quality of life (Dunn & Crawford, 1999; Moving People, 2007) –limiting access to housing and employment –damaging social relationships and social participation –reducing self-esteem and dignity –lack of control and influence in how services are designed and delivered –contributes to the abuse of human rights

24. Barry NOSP April 2010 Stigma Stigma and discrimination are identified as the single most important barrier to overcome in the community (WHO, 2001) Reduce the likelihood of people contacting the services for help due to fear of being labelled and discriminated Reduce the willingness of policymakers to invest in mental health - low priority Importance of tackling stigma and raising greater public awareness from a public health perspective –enable people to engage with mental health in a more positive way

25. Barry NOSP April 2010 Stigma Link and Phelan (2010) stigmatization model –Labelling – differentiate and label human variations –Stereotyping – prevailing cultural beliefs –Disconnection – ‘us’ and ‘them’ –Status loss and discrimination – unequal circumstances Social process – socially shared beliefs, perceptions and cultural norms

26. Barry NOSP April 2010 Challenging Stigma Different approaches –Mental health sector – treatment services and recovery –Public health sector – public beliefs and attitudes –Disability sector – disability inclusion processes –Human rights sector – rights-based approach Challenge self-stigmatization Reducing stigmatization in the community Legislation and policy changes against discrimination

27. Barry NOSP April 2010 Challenging Stigma Large body of international research on the nature and extent of stigma and discrimination in mental health and public perceptions and attitudes to mental disorder Public attitudes - dominated by negative stereotypes Influence of the media – reinforces myths, derogatory language and discriminatory portrayal of mental health –violence, crime, unpredictable, incurable

28. Barry NOSP April 2010 Challenging Stigma Both mental health and mental illness are still associated with stigma in the mind of the public NOSP (2007) report ‘ Mental Health in Ireland: Awareness and Attitudes’ SLAN (2009) – 52% agree/strongly agree that –“if I was experiencing mental health problems, I wouldn’t want people knowing about it” –Scotland 2002 (50%), 2004 (45%), 2006 (41%) (Braunholtz et al., 2007)

29. Barry NOSP April 2010 Stigma Reduction Strategies WPA Open the Doors – (2002.www.openthedoors.com) UK Mind out for Mental Health (www.mindout.net); Changing Minds Campaign (www.rcpsych.ac.uk) Defeat Depression Campaign Scotland See Me campaign (www.seemescotland.org) New Zealand Like Minds Like Mine (www.likeminds.govt.nz) Australia – Stigma Watch (www.sane.org); beyondblue (www.beyondblue.org.au) US National Stigma Clearinghouse (http://community- 2.webtv.net/stigmanet) Ireland – NOSP, Mental Health Ireland, AWARE, Schizophrenia Ireland

30. Barry NOSP April 2010 New Zealand Like Minds Like Mine National programme – mass media campaign –regional programmes contracted out to local providers Mental health promotion approach –influenced by recovery approaches - service user constituency –human rights and disability inclusion – government policy Impacts of the national media campaign –surveys monitoring public response to the campaign messages have shown improvements over the last nine surveys –strong message recall on the support/acceptance/not discriminate theme –specific behaviours in the last 12 months

31. Barry NOSP April 2010 New Zealand Like Minds Like Mine Cost- benefit analysis (Vaithianathan, 2010) –Costs to the health care system and the benefits of the campaign to the population purely in terms of increased employment costs –for every dollar spent on Like Minds $13 of benefit was generated over a five year period –assumption that Like Minds generated only 30% of the change in attitudes and 50% in changed behaviour the benefits still exceed the costs by more than 4:1 –Anti-stigma programmes have potential to generate large economic value – increased employment opportunities for people with mental disorders

32. Barry NOSP April 2010 Scotland See Me Campaign National campaign launched in 2002 – National Programme for Improving Mental Health and Wellbeing –national level publicity campaign – social marketing coupled with a community development approach –targeted campaigns – work with specific groups, the media (Stigma Stop Watch, volunteers), support for local activities Independent evaluation in 2006 –national surveys (2002-2006) positive shifts in mental health awareness and attitudes towards people with mental health problems –media reporting – change in use of negative story lines –active involvement of users and carers –evaluation of reach and recall

33. Barry NOSP April 2010 School-based interventions Mental health promotion in schools, when implemented effectively, can produce long-term benefits for young people, including emotional and social functioning and improved academic performance Traditional topic based health education approaches are of limited value (knowledge only programmes have minimal effects on behaviour) Programmes adopting a whole school approach are more successful and the most promising

34. Barry NOSP April 2010 Systematic Reviews of School-based Mental Health Promotion Programmes Lister-Sharp et al. (1999) Wells, Barlow and Stewart-Brown (2001, 2003) HSRU, University of Oxford Harden et al. (2001) EPPI- Centre Greenberg, Domitrovich & Bumbarger (2001) CASEL (2003) Tennant et al. (2007) Payton et al. (2008) US Mental Health and Substance Abuse (SAMHSA - www.samhsa.gov)

35. Barry NOSP April 2010 Collaborative for Academic, Social and Emotional Learning (CASEL) Essential skills for social and emotional learning: Self-awareness - know yourself and others - identify feelings, be responsible, recognize strengths Self-management - manage emotions, understand situations, set goals and plans, solve problems creatively Social awareness - care for others - show empathy, appreciate diversity Relationships skills - communicate effectively, build relationships, negotiate fairly, refuse provocations, seek help Responsible decision making - act ethically, appropriate social norms, respect others

36. Barry NOSP April 2010 Systematic Reviews of School-based Mental Health Promotion Programmes Three scientific reviews - 317 studies involving 324,303 school children aged 5-13 years (Payton et al., 2008) Strong and consistent support for the value of social and emotional learning (SEL) programmes implemented by school staff Improvement in multiple areas : Social and emotional skills Attitudes towards self, school and others Positive social and classroom behaviours Conduct problems - misbehaviour and aggression Emotional distress - stress and depression Academic performance - test scores and school grades

37. Barry NOSP April 2010 Sample Programmes Whole School Approach -Australian MindMatters programme (adapted as MindOut programme in Ireland- Byrne, Barry and Sheridan, 2004) -Olweus’ Bullying Prevention programme -UK Social and Emotional Aspects of Learning (SEAL) Targeted Programmes - Clarke’s Coping with Stress Course - depression - Gillham et al’s Penn Resiliency programme -Resourceful Adolescent programme (Shochet et al, 2001) -Incredible Years Programme (Webster-Stratton et al., 2001) -Anti-stigma – Mental Health Matters, Beating the Blues -Out of school - Spun Out, Reach Out, Headstrong

38. Barry NOSP April 2010 Zippy’s Friends Programme Emotional Literacy Programme for young children enabling them to: learn skills to deal with everyday problems develop a wide range of coping strategies identify and label feelings focus on positive strengths and abilities think for themselves work cooperatively as a class group

39. Barry NOSP April 2010 Stigma Reduction in the Workplace The role of work and paid employment Mental health impact of unemployment is well documented –EU countries report 20-30% employment rates for people with mental health problems –Scotland – 57% concealed they had mental health problems when applying for a job ; 43% had not gone ahead with a job application for fear of disclosure Evidence-based interventions to facilitate job retention, re-employment, supported employment Organizational approaches - regulatory measures and economic incentives; management and social support Legislation on discrimination in the workplace

40. Barry NOSP April 2010 Effective Stigma Reduction Interventions Underpinning principles (Link and Phelan, 2001; Pinfold et al., 2003; Gale et al., 2004; McDaid, 2008) Multifaceted and multi-level - addressed at the individual, community, organisational and societal level Services users and carers involvement in the design, delivery and evaluation of programmes Clear consistent messages delivered in targeted ways to specific audiences Education approaches alone will not lead to behaviour change - must address discriminatory actions Policy and legislation – social inclusion and empowerment strategies, create an environment of intolerance to prejudice and discrimination Long-term planning and funding Appropriate monitoring and evaluation of interventions

41. Barry NOSP April 2010 Stigma Reduction Promotes Mental Health Improves the social inclusion and quality of life of people with mental disorders Greater openness about mental health problems and willingness to seek appropriate help sources early Improves mental health literacy help people to have a greater understanding of their emotional and social well-being the importance of mental health for overall health knowledge of protective and enhancing factors for positive mental health

42. Barry NOSP April 2010 Conclusions Remove the stigma and discrimination surrounding mental health in order to address the social determinants of mental health and promote positive mental health Engaging the political will to promote mental health at every level of policy Mobilising a public demand for a mentally healthy society - concern with emotional and social wellbeing, social values, culture, economic and social policies

43. 5 th Annual Forum Wednesday 28 th April 2010 Royal Hospital Kilmainham ‘Promoting Positive Mental Health and Reducing Stigma’

44. National Office for Suicide Prevention Annual Forum 2010 Geoff Day Director

45. Young Peoples Mental Health Awareness Campaign Objectives  Encourage young people to know about positive mental health  To increase young peoples understanding of mental health issues  To provide information on mental health in a youth friendly format  To encourage young people to look after their own mental health and support others close to them  To encourage young people ask for help and to let them know it is alright to ask for help

46. Young People & Mental Health National Survey  Isolation is a key theme  Concern about the future  Bullying, drink, drugs and peer pressure  Good understanding of mental health  Family and friends are key networks  Use of online but not the only means of providing information

47. Young People & Mental Health - consultation  Consulted with young people through Dail na nÓg and the OMCYA  Consulted with young people from various voluntary organisations  Focus groups with young people  Ongoing discussions with young people

48. Creative ways to encourage young people to access information & help on website & Bebo page  Launch by Minister Moloney 12 th Oct 2009  Youth appropriate TV advertising  Youth appropriate Cinema advertising  Outdoor advertising i.e. bus stops near schools  Wallet card  Irish student press advert (circulation 50,000 Secondary School students)  Promotional pens

49. TV / Cinema Ad

50. Outdoor 30% of our target audience (185,820) of 15-24 year olds saw the posters on average 16.4 times

51. Wallet card

52. Website & Bebo page

53. Young Peoples Mental Health Awareness Campaign Results of youth appropriate actions

54. Website Stats Results  Total number of visits = 23,598  Absolute unique visitors = 19,378  Unique visitors January – April 2010 = 4,397  Pageviews = 83,074  Average time on site = 2:57 mins

55. Cinema Results The cinema ad ran for 6 weeks from 20 th November 2009 on nearly 300 screens nationwide During this time visits to the website increased from just over 200 per week to between 500/700 per week

56. Bebo social network site  Total number of friends: 1,649  Moderated by NOSP staff

57. Some comments left on Bebo page

58. Our Partners  13 Voluntary organisations  16 Projects (original target 8)  Timeline for project completion - November 2009 to mid 2010  Projects funded by HSE NOSP will include advertising of www.letsomeoneknow.ie www.letsomeoneknow.ie

59. Co-branding projects  Bodywhys  Crosscare Travellers Programme  Cluain Mhuire Mental Health Service (DETECT)  GROW  National Suicide Research Foundation  ‘FREE’ student campaign  RehabCare  Samaritans  Pieta House  Gay, Lesbian, Equality Network  Headline  Teen-Line Ireland  BeLonG To

60. Co-branding projects Results to date  40,000 mental health information packs distributed to students during college mental health week November 2009  Samaritans Christmas/New Year radio advert – 17% increase in callers  50,000 LGBT mental health booklets  Traveller poster competition  Bodywhys connect/online chat room

61. Co-branding in 2010 In development:  Belong To Parents booklet  Traveller youth training manual  DETECT early intervention publicity  GROW resource for young people in recovery  Teenline video to assist volunteers

62. Plans for 2010  Participants at Dail na nÓg  Repeat TV/Cinema advertising  Distribute wallet cards  Advertise in Irish Student Press  Monitor results from co-branding projects  Undertake follow-up to baseline national survey of young people & mental health  Continue consultation with young people

63. Young Peoples Mental Health Awareness Campaign ……..….. It will make a difference ☺ geoff.day1@hse.ie www.yourmentalhealth.ie www.letsomeoneknow.ie www.nosp.ie

64. 5 th Annual Forum Wednesday 28 th April 2010 Royal Hospital Kilmainham ‘Promoting Positive Mental Health and Reducing Stigma’

65. Mental Health Awareness Promoting Positive Mental Health in St. Angela’s College, Sligo Mike Rainsford HSE West Mental Health Promotion / Suicide Resource Officer

66. Background: Local Partnership with Health Promotion and St. Angela’s College Tom O’Grady – Post-Graduate Diploma in Nursing Studies ( Community Mental Health) ASIST and SafeTALK

67. Promoting Positive Mental Health and Well-being Aim: to develop mental health promotion knowledge, skills and confidence, including understanding the contribution that mental health promotion makes to a wide range of health and social outcomes. Students will recognise the positive impact that mental health promotion has at a community and individual level. This module also aims to critically investigate current debates about mental health and well-being. It is envisaged that students will be able to develop and apply acquired learning into practical situations in their own personal lives, communities and their workplaces.

68. Content includes: Designing and evaluating a mental health promotion initiative Presentations Changing health behaviour Recovery and Wellness tools Measuring success Positive Psychology Debating the economic case for Mental Health Promotion

69. Connecting content to local initiatives: ‘Walking Back To Happiness’ Zippy’s Friends

70. Further outcomes: Develop module into blended (e-learning) Positive Mental Health Policy Tom O’ Grady 071 91 35624 togrady@stangelas.nuigalway.ie

71. 5 th Annual Forum Wednesday 28 th April 2010 Royal Hospital Kilmainham ‘Promoting Positive Mental Health and Reducing Stigma’

73. Introduction SEE CHANGE is Ireland’s national programme working positively to change social attitudes and behaviour so that there is a reduction of stigma and discrimination associated with mental health problems and to ensure that everyone enjoys the same rights on an equal basis.

74. Stigma While one in four of us will experience a mental health problem at some time in our lives – many of us are frightened of the idea of mental health problems. The stigma associated with mental health problems is, for some people, almost as difficult to manage as the experience of being unwell.

75. Stigma  A recent Irish study into mental health attitudes found that while 85% of people in Ireland feel that mental health problems can affect anyone, 62% would not want anyone to know if they had a mental health problem. ('Your Mental Health' Awareness Campaign Research Report, HSE’s NOSP, 2007)  Increasing public understanding about mental health problems requires action at every level of society.

76. How can we reduce stigma? Decrease Stigma by… Education Talking openly Quality support and treatment MediaLanguage Personal role

77. Vision of See Change Our vision is that of an Ireland where every person has an open and positive attitude to their own and others’ mental health.

78. Aims/Objectives Reduce stigma associated with mental health problems and challenge discrimination; Create an environment where people are more open and positive in their attitudes and behaviour towards mental health; Promote greater understanding and acceptance of, and support for people with mental health problems; and Empower individual people with experience of mental health problems to gain equality, respect and rights.

79. A media campaign, using national organisations to promote the message. 1. National level A network of national and local organisations across the country that will also carry the message through local broadcasts, local print media and a range of other activities. This will be managed on a county, provincial and regional basis. 2. Local level and discrimination through:

80. See Change Partners so far…

81. Actions to date…  Amnesty’s research to capture individuals’ reported experiences of discrimination due to their mental health problems – findings from this research will help to shape See Change’s work  See Change has commissioned research into public attitudes to inform the campaign (commenced 14 th April, conducted by Millward Brown Lansdowne)  Video promo  Website: www.seechange.iewww.seechange.ie  Follow us on:

82. Most importantly… We want people to get involved from the beginning, to engage with See Change and to help us design the campaign. That is why we are launching the See Change Ideas Competition.

83. Funding See Change has been initiated by Minister Moloney and supported by the Department of Health and Children through a grant from the National Lottery Additional funding has been raised from:  HSE National Office for Suicide Prevention  Mental Health Commission  St. Patrick’s University Hospital See Change will work to raise further funds.

84. We invite you to become part of See Change www.seechange.ie